gis 20102011 slide hematemesis melena
TRANSCRIPT
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Dr. Mabel HM Sihombing, SpPD-KGEH
Dr.Ilhamd SpPD
DIVISION OF GASTROENTERO-HEPATOLOGY DEPARTEMENT OF INTENAL MEDICINE /
FACULTY OF MEDICINE, NORTH OF SUMATERA / H. ADAM MALIK HOSPITAL
PSMBA
PSMBB
HEMATEMESIS
MELENA : (50 ML BLOOD)
HEMATOCHEZIA (TRANSIT TIME <<)
LIGAMENTUM TRAITZ
HEMATOCHEZIA
MELENA (TRANSIT TIME >>)
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PENGERTIAN
HEMATEMESIS :
MUNTAH DARAH WARNA MERAH KECOKLAT COKLATAN ���� KEHITAM HITAMAN (CAFFEIN)
MELENA :
BAB WARNA HITAM (TERRY STOOL) ���� >50CC DARAH
HAEMATOCHEZIA :
BAB WARNA MERAH TERANG ���� GELAP
OCCULT BLEEDING :
TDK ADA PERUBAHAN WARNA BAB, NAMUN BENZIDINE TEST (+) 10 CC
HASIL :GAMBARAN PASIEN PSMBA 2 KURUN WAKTU
(MABEL DKK)
1993-1996 1997-2000
Usia Rata2 54,25 52,32
Wanita/Laki-laki 95/168 78/142
Hematemesis 9/21 (30) 6/31 (37)
Hematemesis & Melena 47/72 (119) 40/69 (109)
Melena 39/75 (114) 30/42 (72)
Kematian 10/263 (0,04%) 6/220 (0,03%)
Jlh Penderita 263 220
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HASILPENYEBAB PERDARAHAN (MABEL DKK)
1993-1996 1997-2000
Varises esofagus 78 55
Tukak duodeni 51 40
Tumor Lambung 51 45
Tukak Lambung 27 33
Gastritis Erosiva 24 26
Gastropati 26 17
Tumor Esofagus 6 4
Jumlah 263 220
Etiologi PSMBA
�
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PENYEBAB PSMBA DITINJAU DARI LOKASI
ESOFAGUS� OESOPHAGEAL VARICES� MALLORY – WEISS TEAR� OESOPHAGEAL CARCINOMA� REFLUX OESOPHAGITIS� FOREIGN BODY
LAMBUNG� PEPTIC ULCER� EROSIONS/GASTRITIS� GASTRIC VARICES� PORTAL HYPERTENSIVE GASTROPATHY� GASTRIC CARCINOMA� LYMPOMA � LEIOMYOMA� ANGIODYSPLASIA (INCLUDING OSLER’S DISEASE)� DIEULAFOY’S EROSION
ULCERATIVE, EROSIVE,OR INFLAMMATORY
DISEASE
Peptic Ulcer disease
Gastro or duodenal ulcer, Z E syndrome, GERD
Stress Ulcer
Infection causes
Helicobakter pylori, Cytomegalovirus, Herpes simplex
Drug-induced erosions, ulcers
Aspirin, NSAIDs, Pil-induced ulcer
Anticoagulation therapy
TRAUMA Mallory-Weiss Tear, Foreign body ingestion
VASCULAR LESIONS Varices, Angiomas, Osler-WR syndrome,Dieulafo’y lesion
Watermelon stomach,portal hypertensive gastropathy
Aortoenteric fistula, radiotion induced telengiectasia
TUMORS Benign
Leiomyoma, Lipoma,Polyp, Blue rubber syndrome
Malignant
Adenocarcinoma, Leiomysarcoma, Lympoma, Kaposi’s sarcoma,Carcinoid, Melanoma, Metastatic tumor
Miscellaneous
Hemofilia, Hemosuccus pancreaticus
BERDASARKAN BENTUK KELAINAN
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PENYEBAB TERBANYAK DARI PSMBA DITINJAU DARI PENYAKIT
COMMON
� ESOPHAGEAL VARICES
� ESOPHAGOGASTRIC MUCOSAL TEAR
(MALLORY-WEISS SYNDROME)
� GASTRIC EROSIONS
� GASTRIC ULCER
� DASTRIC VARICES
� DUODENAL ULCER
� ANGIODYSPLASIA (INCLUDING OSLER’S DISEASE)
� DIULAFOY’S EROSION
OCCASIONAL� ESOPHAGITIS� ESOPHAGEAL CARCINOMA� GASTRIC DUODENAL NEOPLASMS
(CARCINOMA, LYMPHOMA, POLYPS)� GASTRIC MUCOSAL VASCULAR ECTASIA
ASSOCIATED WITH CIRRHOSIS� DUODENITIS� ANASTOMIC ULCER� SUBMUCOSAL NEOPLASMS
(LEIOMYOMA, MOST COMMON)� VASCULAR-ENTERIC FISTULA (USSUALY FROM AN
AORTIC ANEURYSM GRAFT)RARE � NASAL OR PHARYNGEAL BLEEDING� HEMOPTYSIS� ESOPHAGEAL REPTURE (BOERHAAVE’S SYNDROMA)� HEMOBILIA
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HISTORICAL FEATURES IMPORTANT IN ASSESSING THE ETIOLOGY OF GASTROINTESTINAL BLEEDING
���� AGE
���� PRIOR BLEEDING
���� PREVIOUS GASTROINTESTINAL DISEASE
���� PREVIOUS SURGERY
���� UNDERLYING MEDICAL DISORDER (ESPECIALLY LIVERDISEASE )
���� NON STEROIDAL ANTI INFLAMMATORY DRUGS /ASPIRIN
���� ABDOMINAL PAIN
���� CHANGE IN BOWEL HABITS
���� WEIGHT LOSS/ANOREXIA
���� HISTORY OF OROPHARYNGEAL DISEASE
ADVERSE PROGNOSTIC VARIABLES IN ACUTE UPPER GASTROINTESTINAL BLEEDING
���� INCREASING AGE
���� INCREASING NUMBER OF COMORBID CONDITIONS
���� CAUSE OF BLEEDING (VARICEAL BLEEDING > OTHERS)
���� RED BLOOD IN THE EMESIS AND/OR STOOL
���� SHOCK OR HYPOTENSION ON PRESENTATION
���� INCREASING NUMBERS OF UNIT OF BLOOD TRANSFUSED
���� ACTIVE BLEEDING AT THE TIME OF ENDOSCOPY
���� BLEEDING FROM LARGE (>2.0 CM) ULCER
���� ONSET OF BLEEDING IN THE HOSPITAL
���� EMERGENCY SURGERY
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AKTIFITAS PERDARAHAN KRITERIA ENDOSKOPIK
Forrest Ia – Perdarahan aktif
menyembur (spurting)
Forrest Ib – Perdarahan aktif
Forrest II – Perdarahan berhenti,
tetapi masih disertai
kelainan yang nyata
Forrest III – Perdarahan berhenti,
tanpa menunjukkan
sisa
: perdarahan arteri
: Perdarahan merembes
(oozing)
: Gumpalan darah pada
dasar tukak
“visible vessel”
: Lesi tanpa tanda sisa
perdarahan
KLASIFIKASI AKTIFITAS PERDARAHAN
MENURUT FORREST
HEMORRHAGIC I II III IV
CLASS
BLOOD LOSS 15% OR 20-25% OR 30-35% OR 40-50% OR
750 ML 1000-1250 ML 1500-1800ML 2000-2500 ML
HEART RATE <100 >100 >120 >140
RESPIRATORY 14-19 20-29 30-40 >40
RATE
ARTERIAL NORMAL 110-80 70-60 <60
PRESSURE
CAPILLARY NORMAL INCREASED INCREASED INCREASED
FILLING TIME
DIURESIS (ML/H) 35-30 30-25 25-5 0
NEUROLOGIC MILDLY VERY CONFUSED LETHARGIC
STATUS ANXIOUS ANXIOUS
TABLE 1 . HEMORRHAGIC CLASSES
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1. PERDARAHAAN ���� ANAMNESE ���� RIWAYAT
COMMON
� VOMITING (MENTAL) � MALLORY –WEISS TEAR ?
� HEARTBURN & REGURGITASI � REFLUX ESOFAGITIS ?
� DYSFAGIA & BB � � MALIGNANCY PD ESOFAGUS ?
� MAKAN OBAT-OBATAN & ALKOHOL �GASTRIC EROSIVE ?
ULKUS PEPTIKUM ?
� LIVER STIGMATA (CH) � VARICES BLEEDING ?
� PENYAKIT BERAT (DI ICU) � STRESS ULCER ?
DIAGNOSTIK
2. PEMERIKSAAN FISIK :
���� Penilaian status hemodinamik & resusitasi
���� Jaundice & Tanda2 liver stigmata & HT portal
���� Bleeding diathesis : purpura, ekimosis, ptikiae
3. RADIOLOGI
���� Ba. Swallow, Ba. Follow Through, MDF double contras, Kolon in loop.
���� Upper & Lower Abdominal Scanning
4. ENDOSKOPI
���� Gastroduodenoskopi
���� Sigmoidoskopi
���� kolonoskopi
���� Push Enteroskopi
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Gambaran Endoskopi :
Erosi
• Erosi Multipel, warna merah kehitaman,terutama difundus dan korpus
Ulkus • Perdarahan masif bila terkena pembuluh darah• Ulkus akut, de novo ,multipel ukuran 0,5-2 cm, di fundus dan korpus dan kadang kadang diduodenum
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Forrest I
Spurting bleeding
Forrest III
HEMATEMESIS
HISTORY
LABORATORY TESTS AND IMAGING STUDIES
LIVER CIRRHOSIS WITH ACTIVE BLEEDING
YES NO
BALOON TAMPONADE
URGENT EGD AFTER REMOVAL OF BALLON
TAMPONADE
ESOPHAGEAL OR GASTRIC VARICES
SCLEROTHERAPY
URGENT EGD
NO LOCALIZATION
MASSIVE BLEEDING
SURGERY
MODEST BLEEDING
REPEAT EGD OR ANGIOGRAPHY
NO LOCALIZATION
WITH RECURRENT OR PERSISTENT BLEEDING
LOCALIZATION OF BLEEDING
SITE
LOCALIZATION OF BLEEDING
SITE
DEFINITIVE TREATMENT: ENDOSCOPIC (THERMAL
COAGULATION OR INJECTION)OR
PHARMACOLOGIC
Figure 1. Suggested Diagnostic Procedures in patients with hematemesis. (EGD=esophagogastroduodenoscopy)
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MELENA
ELECTIVE EGD
LOCALIZATION OF BLEEDING SITE (50-70%)
NO ACTIVE BLEEDING
RECTOSIGMOIDOSCOPY AND COLONOSCOPY
(WHENEVER POSSIBLE)
DEFINITIVE TREATMENT OR OBSERVATION
RADIOISOTOPIC SCAN
IF POSITIVE, ANGIOGRAPHY
ANGIOGRAPHY
NO LOCALIZATION
SURGERY
Figure 2. Suggested diagnostic procedures in patients with melema (EGD=esophagogastroduodenoscopy)
NO LOCALIZATION
LOCALIZATION OF BLEEDING
SITE
IN CASE OF RELEVANT BLEEDING
NO LOCALIZATION
HISTORY
PENANGANAN
RESUSITASI (UMUM)
Pasang infus / IVFD
Pasang NG Tube
Golongan darah / Cross Match
Transfusi darah jika perlu
Koreksi koagulopati jika perlu
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PERDARAHAN SALURAN CERNA BAGIAN ATASHEMATEMESIS / MELENA
DENGAN GANGGUAN HEMODINAMIK TANPA GANGGUAN
HEMODINAMIK
Syok (baring 50%, duduk 30%)
Atasi hipovolemi Infus / transfusi sesuai
- NaCl RL, Plasma expander kebutuhan
- Transfusi darah biasa / PRC Slang Nasogastrik
Slang Nasogastrik Bilas air es
- Bilas dengan air es sampai jernih Obat hemostatik
Obat hemostatik Monitor Hb/Ht, tensi, nadi,
Monitor Hb/Ht, tensi, nadi, kesadaran kesadaran
Anamnese & Pemeriksaan Fisik Anamnese & PemeriksaanFisik
Perdarahan terus Perdarahan stop
G a s t r o s k o p i
Gastroskopi
Dengan varises Tanpa varises
- Skleroterapi darurat
- Slang S-B + Gastritis erosif
- Sandostatin& Somastotatin Ulkus Peptikum
Mallory Weiss
- Terapi konservatif diteruskan Tumor
(antasid, penghambat H2,
hemostatik, laktulose, neomisin) Konservatif
(antasid, penghambat
H2,PPI
hemostatik)
Perdarahan terus Perdarahan stop
Operasi Konservatif
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VARISES BLEEDINGPROFILAKSIS BETABLOKER (PROPANOLOL)
TERAPEUTIK : SOMATOSTATIN
�MEDICAMENT :
�SB TUBE
�ENDOSKOPI�ERADIKASI
�TIPSS
SKLEROTERAPI
BINDING LIGASI
ULKUS BLEEDING
1. MEDIKAMEN : ARH2, PPI, Antasida
2. ENDOSCOPIC Therapy : ���� laser
���� elektrokoagulasi
���� heater probe
���� topical sprays
���� injection therapy (adrenalin 1:10.000, alkohol & polidokanol )
3. RADIOLOGIC Therapy : embolisasi
4. Prophylactic therapy : * eradikasi HP pd TD & TL* empiric therapy jika HP tdk
dieradikasi.* Analog PG (misoprostol)����utk
NSAID + TL* Surgery utk recurent bleeding
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TOPICAL THERAPY
-Tissue adhesives
-Clotting factors
-Collagen
-Ferromagnetic tamponade
MECHANICAL THERAPY
-Snares
-Sutures
-Balloons
-Hemoclips
INJECTION THERAPY
-Variceal bleeding
-Non variceal bleeding
- Ethanol
- Other sclerosants
THERMAL THERAPY
-Electrocoagulation
- monopoloar
- electrohydrothermal
bipolar (multipolar)
-Heater probe
-Laser
ENDOSCOPIC THERAPY OF UPPER GI BLEEDING
MEDICAL THERAPYPeptic Ulcer disease
Antisecretory therapy,Antacids,Sucralfate,MisoprostolGastroesophageal varices
Intravenous vasopressin with or without nitroglycerinIntravenous octreotideBalloon tamponade
ENDOSCOPIC THERAPYPeptic ulcer disease
Thermal coagulationMultipolar electrocoagulation,Heater probe,laser ther
Injection therapyEpinephrine, Alcohol
Combination therapy;thermal coagulatuion & injectionGastroesophgeal varices
Injection sclerotherapy,variceal band ligationCyanoacrylate injectionCombination therapy;sclerotherapy &band ligation
TumorsTermal probe, Laser ablation,Thermal balloon cateter
SURGICAL THERAPYNon variceal (ulcer,endoscopic, or mallory-Weiss tear)Variceal
Portosystemic shunting,Esophageal transection and devascularization, Liver transplantation
RADIOLOGIC THERAPY Peptic ulcer diseaseArterial embolization, Intraarterial vasopressin infusion
Gastroesophageal varicesEmbolization,Transjugular intrahepatic portosystemic shunting
THERAPEUTIC OPTIONS FOR ACUTE UPPER GASTROINTESTINAL HEMORRHAGE
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VariableScore
0 1 2 3
Age (yr)
Shock
Comorbidity
Diagnosis
Major SRH
< 60
No Shock
(BP >100
PP <100)
Nil mayor
Mallory weiss
No lesion,
no SRH
None or dark
spot
60-79
Tachycardia
(BP>100,PP>100
All other
diagnosis
>80
Hypotension
(BP<100
PP>100,
CHF,CAD,
Others
Malignancy of
GI tract
Blood in UGI
Clot,visible or
spurting
vessels
Renalfailure,
Liverfailure,
diss.malignancy
Score : < 3 excellent prognosis
> 8 poor prognosis
SRH : Stigmata of recent Hemorrhage
Interpretasi Rockall Score
• Skor > 3 : Risiko mortalitas meningkat
• Skor > 4 : Perlu dirawat diruang High Care
Resusitasi Optimal
Kerja sama tim Penyakit Dalam,bedah , anestesi.
• Mortalitas :
• Skor 0 0%
• Skor 1 3%
• Skor 2 6%
• Skor 3 12%
• Skor 4 24%
•
• Skor 5 36%
• Skor 6 62%
• Skor 7 75%
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PSCA
Monitor status hemodinamik resursitasi
Resiko tinggi (Rockall > 4)Resiko rendah (Rockall < 2)
Endoskopi 12 - 24 jam
Endoskopi segera / urgent
endoskopi terapi Perdarahan ulang (10-20 %)
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PENATALAKSANAAN PERDARAHAN SALURAN CERNAKonsensus Nasional 2003
PB. PERKUMPULAN GASTROENTEROLOGI INDONESIA
• O ksigenasi
• R estore circulating volume
• D rug Therapy
• E valuate response to Therapy
•R emedy underlying cause
Prinsip dasar : Ganti kehilangan cairan, Stop perdarahan ! !
Manajemen awal
ORDER
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Resusitasi dan Stabilisasi(1)
• Pasang jarum ukuran 16 dan 18 untuk infus cairan kristaloid secara cepat; Untuk ekspansi cairan intravaskular 1 L, dibutuhkan cairan kristaloid 3 L
• NGT untuk diagnostik dan monitoring
• Terapi antara ( Stop gap treatment): • Somatostatin • Oktreotide• SB –tube pada perdarahan varises
• Obat supresor asam PPI efektif untuk perdarahan SCBA
• Evaluasi dan monitor keadaan dan respon terhadap terapi
secara klinis, Hematologis, analisa gas darah dan status
Metabolik
Resusitasi dan Stabilisasi (2)
• Transfusi darah atau komponen darah diberikan bila Hb < 7 g/dl atau bila ada gangguan koagulasi •Bila memungkinkan upaya diagnostik secara endoskopik untuk mengetahui dan menghentikan sumber perdarahan perlu segera dilakukan.• Perlu dipersiapkan agar pasien dapat ditransfer kepusat rujukan dengan aman• Obat Vasoaktif Dopamin,Dobutamin, hanya diberikan pada pasien dengan Syok hemoragik bila sudah diberikan penggantian cairan yang cukup
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Terapi obat pada perdarahan SCBA
• Supresi Asam : Pilihan utama Proton Pump Inhibitor (PPI )
Omeprazol : 3 x 40 mg IV atau
40 mg bolus, 8 mg/jam
selama 3 x 24 jam
•Obat Hemostatik;
• Tranexamic acid; 3 x 500 mg IV
• Vit K ; 3 x 10mg IV
• Obat Vasoaktif :
• Somatostatin : 250 µg bolus, infus 250 µg / jam , 3 x 24 jam
Oktreotide 0,05 mg /jam, 3 x 24 jam
NATIONAL CONCENSUS ON UPPER GASTROINTESTINAL BLEEDING
MANAGEMENT IN;
Primary Health Care / Emergency Unit Hospital type D(without specialist and endoscopy facilities)
Indonesian Society of Gastroenterology
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NATIONAL CONCENSUS ON UPPER GASTROINTESTINAL BLEEDING MANAGEMENT IN;
Secondary Care / Specialist / Hospital type C( without endoscopy facilities )
Indonesian Society of Gastroenterology
NATIONAL CONCENSUS ON UPPER
GASTROINTESTINAL BLEEDING
MANAGEMENT IN;
Referral Hospital type A
& B(endoscopy facilities are available)
Indonesian Society of Gastroenterology
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TERIMA KASIH